Abstract
Upper airway obstruction (UAO) is a well known complication of cleft palate repair. The aim of this study was to evaluate the efficacy of local tongue base steroid injection in preventing or reducing the lingual oedema that can cause UAO following palatoplasty. Thirty children with unilateral complete cleft palate were included. They were randomly divided into two equal groups. Children in group I received intravenous dexamethasone whilst children in group II received both intravenous dexamethasone and local betamethasone injected at the tongue base. Both groups underwent the same technique of palatoplasty, postoperative breathing was assessed and UAO was rated as mild, moderate or severe. Postoperative UAO developed in six cases (40%) in group I and in two cases (13%) in group II. In group I, it was mild in three cases, moderate in one case, and severe in two cases. In group II, it was mild in one case and moderate in another case. Despite the differences in the number and severity of the condition in both groups, comparison was statistically insignificant. Local steroid injection of the tongue base during cleft palate surgery reduced the incidence and severity of post-palatoplasty UAO.
Cleft lip and/or palate are common craniofacial abnormalities with an incidence of about 1 in 750 live births. It is the second most common congenital anomaly of the body after clubfoot and the commonest congenital anomaly of the head and neck with a predictable racial distribution.
Upper airway obstruction (UAO) due to lingual oedema is a well known complication of cleft palate repair, ranging from mild to severe obstruction, which may necessitate immediate re-intubation as a life saving procedure. Other factors which may contribute to the problem are that repair of the cleft palate displaces the tongue inferiorly and posteriorly reducing the volume of the oral cavity, especially with a wider cleft, where the tongue is usually situated at a higher position. The repair may also reduce the cross sectional area of the nasal cavity and increase nasal airflow resistance especially if a vomerine flap was used to accomplish tension-free closure of the nasal floor. The presence of adenoid in some cleft palate patients may aggravate the situation, because closure of the cleft decreases the nasal airway volume and may cause oedema of adenoidal tissues.
It has been reported that several patients developed macroglossia following palatoplasty, some of which were massive and were managed by re-intubation and intravenous corticosteroids. Reviewing the English literatures revealed only two cases in which intralesional injection of steroids has been used successfully in postoperative macroglossia; one case had lymphangioma of the tongue and the other had traumatic macroglossia secondary to tongue bite.
The aim of this study was to evaluate the efficacy of local tongue base steroid injection in preventing or reducing the traumatic lingual oedema that can cause upper airway obstruction following palatoplasty.
Materials and methods
This study was carried out from February 2008 to January 2011 after being approved by the institutional ethical committee, and after obtaining informed consent from the parents of the patients. Thirty children (18 males and 12 females) were included in the study ranging in age from 10 to 33 months. Preoperative evaluation of all patients was carried out to detect associated congenital anomalies or co-morbidities. Children with fever and/or history of recent respiratory tract infection were excluded from the study.
All patients were selected to have the same anatomical defects (unilateral complete cleft palate with/or without cleft lip which was previously repaired if present), the patients were randomly divided into two groups (I and II) with 15 patients in each. Children in group I received intravenous (IV) dexamethasone 0.2 mg/kg at the time of induction of general anaesthesia whilst children in group II received both IV dexamethasone (0.2 mg/kg) at the time of induction of general anaesthesia and intramuscular betamethasone (Diprofos ® ) 0.1 mg/kg. The calculated dose of Diprofos ® for each child was diluted using bacteriostatic water to make a volume of 1 ml to be injected locally by the surgeon as three equally divided volumes ‘before starting surgical procedure’ at the base of the tongue at three sites, bilaterally at the lateral margins of the terminal sulcus and a single injection in the midline at the same level.
All cases were monitored using ECG, pulse oximetry, blood pressure and end-tidal carbon dioxide. General anaesthesia was induced using sevoflurane 8% in 100% oxygen using a face mask, during which an IV access was established, atropine 0.01 mg/kg, and ondansetron 0.1 mg/kg were given IV. When an adequate depth of anaesthesia was attained, an oral RAE endotracheal tube was inserted and taped in the midline. Anaesthesia was maintained through controlled mechanical ventilation with sevoflurane 2% and atracurium as a muscle relaxant. Perfalgan (paracetamol solution) at a dose of 15 ml/kg over 15 min was used for analgesia.
All cases were subjected to the same surgical procedures; a two flap palatoplasty technique was the method of cleft repair. During the surgical procedures, some precautions were taken to minimize the occurrence of postoperative oedema such as choosing an appropriate sized tongue blade in relation to the oral cavity, releasing the tongue traction for 5 min every 30 min to allow venous return, and ensuring the patient’s head was not low down.
At the end of the surgery, sevoflurane was discontinued, the residual neuromuscular blockade was reversed with neostigmine (0.05 mg/kg IV) and atropine (0.02 mg/kg IV) and spontaneous ventilation was resumed. Upper airway secretions were suctioned under direct vision using a direct laryngoscope to ensure a clean airway, and to assess apparent lingual oedema. When the patient was awake with eye opening and purposeful movement, the trachea was extubated, the patient was placed in the lateral position, and was transferred to the postoperative recovery room.
The clinical manifestations of the patients in the immediate post-extubation period were used to consider the degree of UAO, rated as mild, moderate or severe ( Table 1 ).
| Degree of upper airway obstruction | Clinical manifestations |
|---|---|
| Mild | • Difficult, noisy and rapid breathing that becomes apparent when the child cries and improves completely by placing the child in lateral or prone position • No movement of nasal ala, no suprasternal or intercostal retraction • No decrease in oxygen saturation in room air |
| Moderate | • Difficult, noisy and rapid breathing that improves by placing the child in lateral or prone position, but still noisy • Movement of nasal ala, suprasternal retraction but no intercostal retraction • Oxygen saturation decreases in room air but improves with oxygen mask |
| Severe | • Respiratory distress in the form of difficult, noisy and rapid breathing with increased action of accessory muscles of respiration associated with decreased oxygen saturation • The manifestations do not improve when the child is placed in lateral or prone position or even by inserting oral airway • Oxygen saturation does not improve even with oxygen supplementation via oxygen mask • Immediate re-intubation is required to bypass the obstruction |
Statistical method
Data were coded and summarized using Statistical Package for Social Sciences version 15.0 for Windows. Quantitative variables were described using mean ± standard deviation and categorical data by using frequency and percentage. Comparison between groups was done using the χ 2 test for qualitative variables, Student’s t -test and Mann–Whitney tests were used for quantitative variables. A P value <0.05 was considered statistically significant.
Results
This study included two equal groups of unilateral complete cleft palate patients who underwent palatal repair with the same technique. Group I included 10 male and 5 female patients aged 10–31 months with a mean body weight of 12.6 kg. Group II included eight males and seven females aged 10–33 months, with a mean body weight of 13.1 kg. There were no statistically significant differences between the two groups regarding age and body weight. The associated congenital anomalies in both groups are described in Table 2 . Endotracheal intubation was accomplished uneventfully in all patients using a rigid laryngoscope. There was no statistically significant difference between the groups regarding the duration of surgery; the mean duration was 103 min for group I and 109 min for group II.
| Group I | Group II | |
|---|---|---|
| Micrognathia | 2 | 1 |
| Cardiac septal defect | 1 | 0 |
| Bilateral microtia | 0 | 1 |
| Hypospadias | 1 | 0 |
| None | 11 | 13 |
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